Treatment if your prostate cancer comes back

Your prostate cancer might come back after having treatment to try to cure it. If this happens, it is called recurrent or relapsed prostate cancer.

Your prostate cancer can come back:

• within the prostate gland if you haven’t had surgery to remove your prostate

• in the area where the prostate was, if you have had surgery to remove your prostate

• in the area just outside the prostate

Or it can spread to other parts of the body. This is metastatic or advanced prostate cancer. 

Knowing what to expect and the treatment you might have can help you cope if your cancer comes back.

How you might feel

It can be very difficult to cope with the news that your cancer has come back. At first, you are likely to feel very upset, frightened and confused. Or you may feel that things are out of your control.

It is very important to get the right information about your cancer. And about what your treatment options are. Feeling informed about your illness and treatment can help you make decisions and cope. Your doctor or nurse specialist can give you information.

It can help to talk to family and friends about how you feel. Or a counsellor or your doctor or nurse. 

How do you know that prostate cancer has come back?

After radical treatment such as surgery or radiotherapy, you have regular follow up appointments. During the appointments, your doctor asks how you are feeling. And you usually have blood tests to check the levels of prostate specific antigen (PSA ).

The doctors check to see if your PSA level rises. And how quickly it rises.

An increase in PSA can mean there are prostate cancer cells in your body. You might need treatment if your PSA level rises.

You might hear the term biochemical relapse. This means your PSA level has risen to a certain level after radiotherapy or surgery. You might not have any symptoms. 

You might not need to start treatment straight away. Your doctor will continue to monitor your PSA levels regularly. They watch to see if your PSA continues to rise quickly or stabilises. You might have a scan if doctors think that your cancer might have spread to other parts of the body. 

Symptoms or side effects?

It is important that you tell your doctor if you do have any new symptoms or side effects. Or if you are worried that your prostate cancer has come back. It can be hard to know if physical problems are side effects of treatment. Or if they are a sign that the cancer has come back or spread.

Your doctor can examine you and organise tests if they need to. This will help them to find out what might be causing your symptoms and help you manage any side effects.

Treatment options for recurrent prostate cancer

Treatment for cancer that comes back is called second line or salvage treatment. Many second line treatments are the same as the treatments doctors offer at diagnosis. 

Your specialist doctor and nurse will help you decide whether to have treatment. What treatment you have depends on:

• the treatment you have already had

• your general health

• where your cancer is

• if it has spread to other parts of your body

Your doctor might offer you one treatment. Or you might have choice of treatments.

Treatment options include:

• surgery
• external radiotherapy
• internal therapy (brachytherapy )
• hormone therapy

Treatment after surgery to remove your prostate (prostatectomy)

PSA levels are usually extremely low about a month after surgery. This means they are below the normal range. You may hear your doctor saying that your PSA level is undetectable.

Your doctor monitors your PSA level. If it starts to rise, you may need further treatment. They often describe this as a PSA level after surgery of 0.1 ng/mL or more. But this can vary. 

Your doctor might recommend:

• radiotherapy

• hormone therapy

Treatment after external beam radiotherapy

PSA levels usually go down slowly over months or years after radiotherapy. So it can be difficult to tell when the cancer starts to grow again. Your doctors will look at the trend in the PSA levels. Usually, doctors look for the following signs of recurrence:

• a level of 2 ng/ml above the lowest PSA level after treatment - the lowest PSA level is called the nadir

• 3 PSA level increases in a row

You should ask your cancer specialist if you aren’t sure about this. Your treatment options might be:

• surgery to remove your prostate gland (prostatectomy) if you haven’t had this surgery

• hormone therapy

• a type of internal radiotherapy called temporary brachytherapy

Treatment after brachytherapy

There can be a temporary rise in PSA after brachytherapy. This is called PSA bounce. The level then slowly goes down. Usually doctors say a level of 2 ng/ml above the lowest PSA reading is a sign that prostate cancer has come back.

Treatment after hormone therapy

The PSA can rise after you start hormone therapy. It should then fall and may then become stable or static. If it rises again, this may suggest the cancer is becoming resistant to the hormone treatment.

If hormone therapy is no longer controlling your cancer, your doctor may suggest a different type of hormone therapy. This can be:

• abiraterone (Zytiga)

• enzalutamide (Xtandi)

• darolutamide (Nubeqa)

• apalutamide (Erleada)

Other treatments such as chemotherapy may also be an option. If you have chemotherapy, you usually have the chemotherapy drug docetaxel or cabazitaxel. 

If your prostate cancer has spread

When prostate cancer spreads to other parts of your body it is called metastatic or advanced prostate cancer. Unfortunately,  metastatic prostate cancer cannot be cured. Treatment can help to control the cancer and your symptoms. This might be:

• hormone therapy to lower your testosterone levels
• bisphosphonates to help with bone pain
• radiotherapy to certain parts of your body such as the bones
• radioactive liquid treatment such as radium-223

If hormone therapy is no longer working for you, you might have:

• chemotherapy
• steroid tablets such as dexamethasone

Research

Clinical trials research aims to improve treatment, by making existing treatment better and developing new treatments. Your doctor might ask if you are willing to take part in a trial.